U = U is studied in sexual transmissions, not bloodborne contact
PEP: post exposure prophylaxis
PEP: percutaneous mucous membrane or nonintact skin exposure to blood or visibly bloody body fluids of patient with known HIV infection
Truvada + ritonavir boosted darunavir
https://www.hiv.uw.edu/
ESBL e. coli
zosyn gets great urinary concentrations
Isoniazid daily for 9 months
what are we treating with this?
Treating latent TB, no CXR
don't have any signs or symptoms of TB on CXR
okay I am Dr Hillary iskin I am one of your gim faculty and I work at the
Belltown clinic and I am recently graduated from this Residency program in June so I know a lot of you
and I have with me today Dr will Simmons one of our wonderful ID fellows and he's
agree he's graciously taken time out of his clinical schedule to be here with us today so we'll pick his brain and then
let him go free so this today's session is going to be a
mix app review probably most of you are familiar but for those who are not mix app or the medical knowledge
self-assessment tool is a board prep tool that the r3s are hopefully becoming
familiar with but it's a question Bank not so different from you world that we use to prep for the boards and it's
created by ACP and you can buy it with your professional development funds so
what I've done today is I've gone through the Infectious Disease questions in the mix up qbank and I just
High graded a few of them the ones that I thought were the most interesting the most relevant or in some cases the ones
that the majority of mix-up respondents got wrong so that we could talk talk
them through um just a few things before we start um I'm hoping Kayla will be monitoring
the chat for me although I will say at any point feel free to just unmute and jump in these sessions are are better
when they're Interactive and if my audio or video drops out maybe Kayla will let me know and then please
forgive me in advance for any technological issues that come up through the session
um so the format is we will I'll briefly show the questions stem on screen
um you should have already seen the questions had a chance to talk through them in your breakout groups and then javel will launch a poll we'll give you
guys about a minute to put down to put your nickel down on what you think the answer is and I would encourage you even
if you're not sure to just to please go ahead and commit to something I've I find that the learning is better if you
have to force yourself to to really be tested and then we'll take a step back we'll review the the correct answer and
we'll talk a little bit about the background of the question any any questions or concerns so far
okay all right and I should mentioned neither of us has any disclosures or conflicts
of interest I suppose my only comment is that I'm a generalist not an ID doc
Learning Goals
um and our learning our learning goals here we're going to flip through several high-yield ID topics
um looking to pull out general principles where we can and then also just to get you guys familiar with the
question format okay so we have our first question here I'm not going to reread it
um but I'll let you guys skim it and then these are our answer choices
let me know if anyone wants to go back to the stem again
okay so you guys predominantly chose answer
Choice B 90 of you did and you are right and not only that you
do better than mix that where only 45 of respondents got this question right um
does anyone who got the question right wanna talk us through why they chose this answer
anyone in the Madison Clinic here I I can do it I feel obligated to you in some ways thank you Kevin
um so basically the questions trying to get you to pick Pap with post exposure
purple access and pep is basically Truvada plus an integrase inhibitor and
usually we actually use dolute Tech Revere but for specifically occupational exposure
um the studies that like uh studied occupational exposure user all tag Revere so that's like if you're
doing like the data driven stuff um you start roll Tech Revere and and tenafavir and emphasitabine that's both
of those in combination are Truvada um so that's what pep is
um and and actually this is what folks will get started on the Ed and then they'll
come to the Madison clinic and get switched to Dollar Tech Revere because raw tiger versus bid and that's no fun
um rather do it once daily and I I thought like maybe for a second like oh if they're undetectable like
maybe we could like not put them on pep but um actually like U equals U isn't
studied like we don't really know um for bloodborne like U equals U
specifically is for like sexual uh exposure so determining the source
patient's viral load while helpful information and maybe could tell you that it's probably lower risk like it
doesn't you still would want to start pep amazing thank you so much Kevin I'm so glad that you're on academic half day
today um can you can you share with the group What U equals U is for those who may not know
yeah U equals U is basically undetectable means untransmissible so
you can't transmit your virus through sex um it's based on like a study well
multiple studies um but um following 1600 uh Sierra
discordant couples where one's HIV positive and one's HIV negative and is
long at and they followed them over 10 years so it's like hundreds of thousands of sexual encounters theoretically and
as long as the HIV positive partner was taking their meds and remain undetectable there was generally no
transmission um I say generally because there were some cases of transmission but they just
um there were issues with adherence and things like that so amazing you can feel very confident
that's great and I also heard you say something about whether the exposure is occupational which in this case it was
versus non-occupational and I put just this little graph here showing that it's incredibly unlikely
to a acquire HIV in occupational setting but maybe I'll maybe I'll turn things over to will to give us his thoughts on
this yeah totally agree I agree with everything Kevin said um this is a pep question so with all
pep questions you're always thinking you know what's the risk from The Source patient and they almost always give you an unknown patient to make your life
more difficult what's the risk of the exposure um which uh which is usually basically
was their blood involved you know if a fluid is not visibly bloody or had blood on it
um you you generally don't care so patients can throw their feces all they want we're not giving people pep
um and then you know the risk to the patient which isn't um or what the kind of person who got stuck which doesn't
matter for HIV but sometimes they'll give you a hepatitis B question and then if the patients got proven immunity with
like a positive surface antibody you don't need to prophylax them in any way um and then once you kind of match those
three together you decide whether the person needs post-exposure prophylaxis
um and so I think I don't really have that much to add it the Royal Tech Revere thing is in part the guidelines for
non-occupational and occupational pep are written by two different groups the OPEC guidelines are older
um and so haven't kind of moved over to W but probably will when they next update um it's nice that it's once daily
um the other answers just for for those of you who chose them uh a is prep so
that's what you would put uh someone on who is you know had pre-exposure but is you know high risk
um for potentially acquiring HIV and that's generally once daily you can also do it in like a kind of just in time
approach but uh I doubt they would test that one on the boards um and then C is a reasonable regimen
um for uh for HIV um it's actually not first line anymore
either but we don't use it for pep in part because tolerance is important with pep and that regimen will be less well
tolerated probably a little less effective to um and then for the source patient
spiral load I think we've been discussing this in the chat but um
but basically it's that uh that takes time you know you ideally want to start
pep Within 72 hours for HIV within seven days for Hepatitis B
um and so you don't want to wait for that you should check their viral load um you know if if the patient's available most of the time they're not
but if it's zero if they're totally undetectable I think you know it's something where you can have a
conversation with the patient and potentially consider stopping pep you know I think if if a lot of ID doctors
if they were exposed and their viral load was undetectable would probably stop pep on themselves that being said
people there's a lot of kind of fear around HIV um and so most patients even if the risk
is unbelievably low will still continue pep in in my experience
um so it ends up not manage mattering that much it stratifies the risk of transmission it's probably unbelievably
to zero if the patient's fire load is undetectable but we haven't proven that it's zero and especially because you
know there's kind of CD4 cells that come with the blood and those can have virus in them that's not detectable on a viral
load blah blah blah blah you never get the virus out of the person's CD4 cells there's a theoretical risk that isn't
really as present with uh with non-occupational um exposures
um and then I think we were looking at that slide for risk um with uh the yeah this one the
interesting thing with this is it's just how effective pep is I doubt they'll ask you but um there's been no occupational
Transmissions of HIV in the past more than 20 years except for that one in 2009 which wasn't uh a patient actually
that was or I think it was 2008 or 2009 that was a lab worker working with an HIV culture
um who got a needle stick in that setting and there was a transmission but no one has gotten HIV from a patient in
more than 20 years who took pen um and then oh yeah on the left here kind of uh buried a little bit is uh
post someone who's on pep they get tested when they start pep to make sure they don't already have HIV in the New
Testament six weeks and four months so the six weeks is two weeks after their pet finishes and then four months later
to make sure you're not missing like a delayed conversion um or something like that but I think
that that's probably a little less likely to be tested um yeah I think Kevin covered all of it
Question 1: HIV PEP
amazing and I just put at the bottom here that the national HIV curriculum which is where where I go is where I
would go if something like this came up in clinic make sure I'm doing the right thing anybody with any other questions relating to this this first question
oh yeah and in real life give everyone who's on pepso friend
all right let's move forward then question two
Question 2
the slide is full of text but again I I'm hoping you guys already had a chance to review this
so I will flip to the answer choices
nice okay we got our poll results and I I don't know if you guys can see these but 75 percent of you chose answer
Choice d and that is the correct answer and again
you guys are reading mix up by a pretty wide margin um okay and maybe again I can ask anyone
who chose the correct answer you want to comment on why you chose that
maybe somebody going into Plum crit wants to talk to us about this one the culture lies
tell what do you mean by that Mac how can a culture lie well the mic's for esbl aren't always
going to be um interpretable in the same way that we interpret mic's or sensitivities in
other organisms um and then we were also reading that there are cases if you switch to
uh you know sellings or stuff was performed or things like that there's increased rates of failure when you
narrow and so um going to carbonum based therapy
seem to be the the vibe and you are right and exactly like you said go ahead
MDRO
I was gonna say I actually think will taught me that when I was on ID consults amazing full circle
all right um will you have anything else to add on this case
yeah I think it's this one's like the top line is if they they will probably tell you it's an esbl but if they say
esbl the answer is always carbapenum um in the book um if you see Ceftriaxone resistant you
should also really be thinking about a carbopenum um I think this is probably the most testable of the drug resistance uh
things that they could give you um as a clinical side knot for the test if
this patient was improving on piptazo I might actually leave them um just because piptazo gets great
urinary concentrations though since this patient was septic maybe not um and they are actually revising the
piptazo breakpoints to um try to be a little more accurate there's a the debate on piptazo for at
espls is ongoing and acrimonious and don't ask Derek Fang about it
um basically there was a big randomized controlled child um yeah chat GPT is wrong
um there's a big randomized control trial on this that was uh unfortunately the
micro lab for the randomized trial really screwed up the Pepito break points
um really bringing into question the results of the whole trial but the trial showed the piptazo patients did worse so we still run with that but the answer is
carbapenum either or Miro is fine if you see aspl
um so I don't think piptazo or cefepime would be a correct answer here if it wasn't enterobacter so suggesting more
an amp C based mechanism than cefepime could be a reasonable choice if it tested susceptible
um but this is not one of those this is an E coli and they tell you it's the sbl such as carbopenem every time
um also fine to remember other thing to remember is that you know non-betal actemes are fine so like if this patient
was ready to go and they were backed from susceptible you know that would be a totally reasonable step down therapy
it's okay to step down to things just not to things that are you know non-carbon and beta-lactams
um yeah I think esbl is probably by far the most testable thing for drunk resistance me I think AMC is probably
difficult to test especially since those were got revised about two years ago I feel like it takes three or four years
for new things to show up on the boards uh but remember in tarab actor and
klebzurology news X and terabacterogeneous are the two big MC players
um yeah any other questions about this I would not add jet for Synergy
um yeah I think this is a pretty unfortunately I remember theft tracks on
resistant equals espl equals mirapeno nice all right awesome okay
Question 3
we're gonna keep moving forward here I had to include a tuberculosis question because it's ID
and gonna slip forward here to the question stem
okay and 84 of you chose answer key
and you are right um this is he's going to get daily ice
and eye is it for nine months does anyone want to share with us what are what are we treating with this
oh I can share uh we are treating latent TB here because they had a positive pant
of her own but their x-ray did not show any nodule active TV they don't have any symptoms of active TV or like other
non-pulmonary TB um we talked about that the guidelines has just very recently changed uh to I
think moving Griffin as a first line but we thought that the board would not reflect it yet
um and uh but we still like to create that in uh TB and this is the duration I had a lot of patients who don't tolerate
the eyes and eyesight and I think this is part of why they change the guidelines um
um yeah amazing thank you so much Aya and you are absolutely right we're treating latent TV here they don't have
any signs or symptoms of TV on history and like you said exam and chest radiograph don't show any signs of
active TV um maybe I'll turn it over to will I just put a diagram with the regimens here
yeah so I agree this is latent TB for those of you who are paying a lot of attention some jerks decided to rename
all of this so it's now tuberculosis infection is latent TB and tuberculosis
disease is active TB which I hate um I hate it when people rename things
that I've gotten used to but I'm sure they'll probably still be calling it latent TV on the boards
um I agree isonize it is a reasonable regimen um anyone know what you should be giving
the patient in addition to isonize it if you're giving them isoniasis
yeah there we go paradoxing I think it's a little weird that they didn't include it in the answer choice but good
everyone's all over that um the other options the three HP or
Isis that is in referentine is actually a regiment they just uh gave it to you for
the wrong duration they gave you 24 weeks instead of 12. but if that was 12 weeks that would actually be a totally
reasonable regimen um that is nice as dot for patients who can't keep track of pills
um the third option is full dose treatment which this patient does not need
um and then no treatment or testing you know not unreasonable
um but uh but probably not what you would choose on uh your boards
um like like uh you mentioned four months of profampin is probably the most
common Choice um it's daily or phamping for four months
um it works just as well if not better than ice and eyes it has better adherence often has fewer side effects
um probably less toxicity all these regiments the toxicity is liver toxicity but you don't monitor lfts unless
someone has Baseline liver function abnormalities you just cancel them on you know cost if you turn yellow
um what else is good to know about Laden TV
I think that's it um um oh Rifampin the main reason we don't put that in is is uh the main reason
someone ends up not on her fampin is usually the drug interactions you know they're on a anticoagulation or
something else that you really can't immunosuppression something you can't safely adjust um and so that's why like in the
transplant World they all get ice and ice and at least until they have a new liver um and even then
um I guess the the main confusing thing with LTB is uh is who you test because
everyone you test you can test someone if you're not going to treat them right and so the groups that you should test for latent tuberculosis I think of them
in like two big buckets is people who are at um high risk for reactivation and then
people who um something really bad would happen if they reactivated
um and so you know in terms of higher risk for reactivation obviously all your immunosuppressed people and then people
with recently acquired TB so your risk of TB is the highest in kind of the two to five years after or activating
reactivating is highest in the two to five years after infection so P this is why we test people who are you know
recent immigrants from an endemic area people who've recently spent time in kind of shelters jails other areas or
with close contacts of uh active TV cases is because this initial period is
higher risk um and then you know your immunosuppressed people bad things will happen if they reactivate so oncology
patients grants my patients patients with HIV uh tnf Alpha Inhibitors kind of all those groups Brokers
um and then the last group that is weird for the US that is I don't think
testable on the boards but just good to know is the U.S tests everyone from an endemic area in the guidelines even if
they're more than five years out I think you know many people think this is a stupid approach if you you know
immigrated from an endemic area 30 years ago and you have a positive tea
spot like your odds of reactivating 2B are probably no greater than you know
someone who acquired it as a child who's not from the endemic area like being from the endemic area itself doesn't
increase your risk um and so I often you really consider whether you need to test those patients
um but the U.S guidelines recommend that everyone from an endemic area be test screened and treated if you know if
positive a lot of other countries will stop screening them once they're more than like five years out from
immigration not testable but just for general medicine purposes uh John asks
do I suggest using the uh those tools I think those tools are great they're a
nice way to kind of put in front of the patients I think they're helpful when you've got a you know a quads or a skin
Latent TB
test that shouldn't have been done um and then you're like do you really want to go through with this because I
think they're a nice way to kind of show the patients the risks of complications from the medications as compared to the
risk of developing TB because in some patients it's really just not worth it and they should just you know watch for
active symptoms of TB so I think they're helpful in those cases you know ideally if you set the test you should have you
know been planning to treat them if you've got the test back because they were high risk but we see tons of these where people send tests that shouldn't
have been sent and then I think it's a super helpful tool I think it's a great tool um
what else about latent TB um the only other thing I guess that's worth remembering is uh I don't wouldn't
memorize them but remember for skin tests which I think are probably less and less likely to get tested on as time goes by the size of induration the
underrated area is the part that makes it positive and how big the induration needs to be to count as positive gets
smaller the higher risk you are so someone with you know active HIV is you know five millimeters will turn them
positive whereas someone who has no risk factors and is not high risk 15 millimeters will turn that positive so
it's a little weird but you need like smaller and so they try to make the test essentially more sensitive for people
who are higher um so you can have a relatively small amount of integration like six
millimeters is positive in someone who's high risk whereas you know in a healthcare work with no medical problems wouldn't be a positive
um but I wouldn't memorize that but just be aware of that um yeah other questions about uh latent
TB I think uh I'll get a chest x-ray in everyone before you treat them and uh yeah TB
lymphadenitis as internet here is the most common extra pulmonary manifestation in active TB
um looks like we got a follow-up question on Steph tracks on resistance to espl uh
yes in most situations uh for gram negatives that aren't amp C producers
basically um AMC produce producers which includes pseudomonas
it's a more complicated question um but for non-ampsi so not entire factor clubsarajis or pseudomonas I
assume I'm dealing with the sbl until really proven otherwise when I see subtraction resistance
all right that's all I got amazing all right I'm going to bring us here to
Question 4
question four and we'll flip over the answers just let
me know if you want to go back to this question stem
sorry well just wanted to ask a quick question about the last question before we went on do we need to do any
retesting for the patient after they treat them for a complete course okay no
um there's there's no point the tests are like like a syphilis antibody or an immunologic test they're going to stay
positive forever some patients do revert their quantifier on um but that's not well studied in any
kind of useful way to be like oh this was successful versus not we just assume if they took all their pills they're
successfully treated knowing that all of these regimens don't have 100 success rate you know they're depending on who
you ask and how good the adherence was 70 to 90 something percent um so if the only thing you would do is
you know if the person has symptoms concerning for active TB after treatment for latent TB knowing that it's totally
possible and you would work them up for active TB but you would there's no reason to repeat a quantifier on our
skin test once someone has had adequate treatment for latent TB I have a follow-up question to that
um so let's say we treat the latent TB and then the patient had another
their exposure and we're worried about them having latent TB again is their tests that we could do now because that
one's always going to be positive you got to decide whether to retreat them I see um so sometimes we will so like uh
especially in patients who are higher risk of say someone who got treated for ltpi as a child you know had a positive
you know skin test or Quant then and then their partner you know 20 years later their partner got active CB
um and they were living with them for like five months before the diagnosis um will empirically treat those patients
um but there's no test that's useful I mean if you know the person's Quant reverted um which is uncommon because one you
should never have tested that and then it turns positive again like that would be helpful but we don't test so I
wouldn't do that you would just kind of based on your clinical assessment of the risk decide whether to empirically Retreat them
and in that case is there any evidence or data demonstrating that you can use the same treatment use the first time or
if you should try an alternate first line treatment for latent TB same treatments fine the idea being that this
is a different TV that they've acquired right so it's it's not like this one they had before has kind of recalled
latent TB and you know there's a conservative drug resistance because they're exposed
um it's the ideas they were re-exposed to a different strain of TB which has no reason to be any more drug resistance
resistant than any other you know TV um if someone had latent TB got treated
and they got active TB after that like you'd be a little worried about drug resistance maybe
um but that's part of why Rye passed four drugs when you start out is to give you time to try to find out if there's drug resistance
so no I would share you with whatever regimen was best for the patient the second time around too thank you
awesome questions are you guys still working on the poll for question four oh here we go all right and you guys most
of you chose answer Choice a at 71 21 24 did choose answer Choice B
um and those of you who chose AR ride and again you're you're beating mix app so great job
um let's see and most of you avoided kind
of the Trap of the the lower down answer choice says um does anyone want to talk us
through why they chose that answer
because the kind of cannons were listed listed first on up to date before is all
Mac you can't use up to date on the boards that's how real practice is
right on both counts um and the main teaching Point here is
that Canada in a blood culture is not a contaminant
um well maybe I'll maybe I'll invite you in here never ever ever ever ever contaminant
um but yeah to stop being the web um the kind of candidates are the correct Choice
um for I think a couple reasons actually um one is like as mentioned on this slide some Canada species are
intrinsically azol resistant um and so you want to hedge against those and there's a lot less resistance
to Mica function it's extremely rare um and so I think Micah is the best
choice um and then for that reason but then I also
actually would choose it even if you knew it was um like albicans which is generally and
eminently fluke susceptible you should still choose a microfungent as your empiric therapy
um just because one you want to make sure you get senses two at least I the reason I do it and this is way too in
the weeds so turn off your brains if you're just looking for mix app but in uh Canada endocarditis even in fluke
susceptible isolates the patients do better if they get Mica up front and then step down to fluke rather than
going straight to fluke even if the isolate was flux susceptible the whole time I think Mike is just probably a little bit better at murdering the uh
the candida up front for some reason um and so I choose Micah up front and
then step the patient down um yeah I think that's about it uh uh it's
totally fine to step down to when it is on when it's susceptible I agree with looking for Canada in people's eyes if
they've had any kind of significant Candia up those against this um because they did a review that it was
rare um and then someone else did a review that
they were like less than 0.9 of Canada has eye involvement and then ID did a review where I found it was a bit higher
like two or three percent which is high enough that I kind of think about it more um so I I you know if they ask you if
someone should get an eye exam if someone had candidemia and they have anything suggesting vision changes or
significant Candia or endocarditis with Canada um an eye exam is probably not a wrong answer uh
let's see this is the Canada Wars thing yeah yeah cdc's yeah Canada Oris has
been blowing up uh Nevada's been having an insane outbreak for um gosh must be of course six months now
Candidemia
it's kind of flown under the radar um and then uh and we're just waiting for it to show up in Washington State uh
how do you murder candidate Oris often make a function um Canada Oris tends to be microfungents
susceptible uh it can develop resistance but uh but Micah is still not the wrong
choice up front
yeah Micah equals murder that's like no side effects it's like the best drug turn up the dose as high
as you want you heard it here first I've given someone more than 300 of
mycofungia they were fine they were not fine but
they tolerated the drug other questions about Canada and candidemia remove all lines with Canada
it is not when you can treat through the line I don't think that they would uh
I don't think they would test you can tough to write a question
um yeah so I think all I got on Canada
anybody else got a question yeah chat Chad's gone off the rails
I'm I'm intentionally ignoring it I can see the red flashing numbers I can't get distracted all right okay
Question 5
question five um
you guys saw this one already here we go over to the question
answers
okay all right we've got our poll results in and 61 of you chose answer Choice a and
we're pretty evenly split through the rest um this was a trick question sort of
um the answer here is Gentamicin someone one of the lucky few or one one
of the few who knew answered that this answer was Gentamicin would you would you talk to us about why you chose that
or maybe what you talked about in your breakout groups about this question
one of the things that came up for us was that this is some weird
outbreak at a political rally that's like maybe some
terrorists like bug like bacillus and racists or like one of us also thought
it was like maybe yoursinia or whatever like I don't know there was some weird stuff going on
um with bioterrorism so we were split between either D C or D
um but we don't really totally know what the organism is nice thanks so much Kevin
and whoever thought it was yercinia is right
um mix up loves to ask these bioterrorism questions
um and if you're it also this wasn't Anthrax in this case but they do also
like to ask about that you're going to treat that with with the antibiotics listed here but for plague you actually
want to use Gentamicin um will you teach us a little bit about that
no I mean it's like uh it's bioterrorism questions I hate them
um so uh technically probably all of these answers are wrong
um because if it's bioterrorism the CDC actually recommends you use two active agents for concern for engineered drug
resistance that the terrorists are very good and have engineered resistance into their uh mnemonic plague so technically
you use gent plus another agent and I'm often acquitted but uh gent is the correct answer here because that's the
Pneumonic plague
go-to use for non-uh drug for non um bioterrorism plague uh I think there
was a plague case in the Miku at UW uh last year once tats all died unfortunately Ash made the diagnosis
already but um yeah there's a couple bioterrorism things that they can ask you about the
gram-negative Cox obasili is or they're often more gram-negative peroxide they can also give you coxal facility is what
makes it plague those two larimia would be a full-on-gram negative Rod fluorimius also gent so if you thought
you still would have picked gent um if the patient's really sick which this one is otherwise quinolones are
fine um I guess we can rattle off the plague again so you're sending a pestis this one is either mnemonic or Bubonic plague
bubonics are like big bubos they're like essentially look like a massive lymph node they appear in areas where there
are lymph nodes um and gent is the correct answer uh per
plague uh Cipro is trophy if someone has plague um tularemia is more commonly you know
animal or tick exposure but can be a bioterrorism agent they tend to have more diffuse infiltrates and higher
adenopathy um but they'd have to give you more clues that's a gram-negative Rod oh the
coughing up the bloody sputum is classic for uh yarcinia or for mnemonic plague
um so that was one of the clues in the question stem um other ones uh Anthrax
um uh is I think the main thing with ancest
is it's not transmissible person to person um so there's no prophylaxis needed I feel like sometimes that gets asked for
some reason where the other ones do need prophylaxis or play does need prophylaxis Anthrax member can have the
cutaneous s-shar or the widened media Steinem is the test question Anthrax gets treated with like three or four
drugs so they will not ask you about treatment smallpox looks like smallpox I don't think Tech
reviewer map would be on the test but vaccinate everyone within a million miles if there's an exposure uh
and then uh what else I think those are the big ones oh botulism just anti-toxic
descending paralysis into bacteria but yeah these bioterrorism questions
I'm not sure I would spend a lot of time on them but they all they're always there I feel like every Board of view
I've been gone through there's been these questions and then there's always
some like your exposure biotherapist I don't know if it became mandatory after
September 11th or something but uh this is mnemonic plague treatment gent telluremia also treat with gent
Lem loans are not a bad answer for most other things yeah and in the non-bioterrorism setting
I think sometimes we forget that our whammy regions may may have more cases of these and like Bill said that patient
there was a patient at UW last year who got mnemonic plague at her home in the one of the Miami States and then was
transferred to our ICU for care so it does come up again it was not a bioterrorism case
um anybody else any questions on this
that was basically everything I know about these so if you have more questions how many cats did she have
she's got a lot of cats from what I heard not enough
never enough all right I got another question for you
Question 6
here um
right Kevin is readying his knowledge their knowledge
okay
okay all right we're kind of split here 55 said answer Choice a 42 said answer
Choice d reassuringly none of you wanted to stop Art thank you for that okay and
you guys were you guys were right here and we're going to continue this person on their current treatment
HIV in pregnancy
um let's see maybe will any other thoughts
here yeah I think nowadays this has gotten a lot easier almost never change someone's
art when they become pregnant um they're there used to be some regiments that were a hard change there
still are some regiments that are a hard change they're art but they're drugs that like no one is on
anymore um so so so you should almost never be changing
someone's entertaining pregnancy um Kobe assist that boosted regimens are the most common Bugaboo because their
levels become much less reliable then it's like a you know discuss with patient um
you know whether they want to take that risk and watch them closely or change them to a non-code assistant boosted regimen
um but everything else it's like almost always keep them on their current regimen if they're if they're suppressed if they're not suppressed please try to
suppress them um but uh but if they're suppressed just leave them alone
um they're I could be like a couple years ago there was a big worry about doll utegrity or neural tube defects
that has since been proven to have been fake news so you take Reviewer is fine if they test you on that
um but I think that and never stop someone's art uh agree
um if the uh uh the I guess the only other thing which you won't get tested
on does Adobe brings your rings about with pregnancy for those of you who chose that one because that's what we
use for perinatal transmission prevention um if the mother's viral load is more
than a thousand I think um at delivery uh this patient is
suppressed so we probably wouldn't do that if they stayed suppressed um but also we don't use that as their
primary HIV regimen um yeah I think basically the risk benefit
is all almost always in favor of keeping them on their current drugs because preventing HIV transmission for the
child is or to the baby is the most important thing uh and the risks of most
art is relatively low um in pregnancy so don't change people's
regimens unless they're failing them is generally the answer in pregnancy
mixav includes a lot of questions on pregnancy um so that's that's part of why I threw
this one in two yeah okay and I think that is our last
Learning points
question here so I've I've summarized a few of our learning points um
again carbopenems for esbl producing organisms Canada is not a contaminant
uh expect expect to mix up to throw bioterrorism questions at you and please
don't take someone off art um maybe we'll just I'll just open up
the floor a little bit for questions about these things more General pick your brain ID questions if if Will's up
for it if we have a little bit of time left so far away guys
everyone's in the chat nobody nobody's talking out loud um
I I uh I started typing things in response to Max question um the in all sort of since the board
there's an R3 Board review Dave at the end of the year for all of you
Hillary can speak to it because she recently went through it and hopefully it was good preparation that is one of
the topics covered the board pass rate it is higher than the 66 that Roxanne put in there
um I don't have the latest numbers but it is actually much higher than that and uh traditionally we we do very very well
we have anywhere between zero to uh one year we had two people who didn't pass it on the first attempt and the ite
score often correlates with risk for not passing on first attempt so if you are
in a lower score range please be in Communications with your Mentor your APD
yeah and guys I intentionally chose questions to try to stump you there are a lot of other ones that you're going to
know right away so don't let this session make you feel like you're going to fail
and I also will say uh mix-up questions are harder than board questions board questions because
they're such high stakes are written to be much more uh straightforward and
um there aren't these tricky Like A and B are correct but you have to do a first and B slightly later and that sort of
thing none of that's in there because it's so high stakes I will say if you want to let a little
bit of panic from this session compel you to start studying it's not a bad time now if you're if you're graduating
this year it's not a bad time to buy your qbank and start doing a couple questions a day just to get a little
familiarity all right anybody have any more any more
ID questions we can
I just wanted to clarify I know the pass rate is like in the 90s but the I I
thought the number of questions you need to get correct is like 65 to 70 or something
like that what is our program's password I wonder
I think it's not from what John said it sounds like it's like very very high there's been like a couple years where
there's like maybe one or two it guys we're gonna be fine Hillary I was asking that question literally to like Stress
Management like aim my like my setting like appropriately not like this is not
step one I'm not I'm not worried I don't think yeah I'm fine okay sorry well I
don't have any like good ID questions I do you want to talk about cerebral malaria no yeah maybe no
hey the good thing about servable areas it may not get me called in overnight anymore
wait what tell me what so yeah you used to yeah if people have questions that
are more germane to either medical practice or uh the boards feel free to ask them before
this uh or just interrupt um yeah we don't need
to carry your meds from Seatac anymore basically so the for those of you who want ID fun facts ivr testonate which is
the train of first degree remote area was not approved in the US because the C FDA requires you to have U.S trials and
no one ever did a U.S truck though it's the standard of care in the rest of the world and who recommendation so the CDC
had a stash that you could use as stored at the quarantine station SeaTac being the nearest one that you could basically
get this technically non-approved drug for like research purposes um for patients with cerebral malaria
the FDA recently decide and CDC decided they were sick of this approach and
approved the drug a couple years ago now um and so basically have phased out the
quarantine stations and as of sometime last year you can no longer get it from
ctac and it's now available through a commercial Drug Company the problem is that company is based in like North
Carolina and this drug costs a ton of money so a lot of hospitals don't have an incentive to keep it on for on
formula already keep doses in-house because they expire within you know not a tiny amount of time but they expire
and you could not have a cerebral malaria case in that time and cerebral malaria is an emergency and so getting something flown from North Carolina is a
pain in the neck um and it's super expensive to keep UW has decided to keep
um basically a course on uh on formulary so we now have it in-house
um and uh and basically we share it between Harborview UW and children I
forget I forget where we keep it was that was that like changed or like was that decision made after because I had I
mean yeah it's relatively new it's since that case we just approved it at TNT uh like a
couple months ago um I also feel like basically CDC didn't want to deal with the question and now
it's going to cost us a ton of money um but the reason ID had to come in was because we had to look at the smear and
talk to the CDC and say this is cerebral malaria please give us your drug and now theoretically you'll just be able to
order it it's probably ID approval still but that was the one thing that got an ID fellow in overnight generally
um there's always like every year there's one person who got brought in that's fine but maybe not anymore sorry
that's great we'll have UW we'll have UW spend money on that as opposed to paying us more
yeah and without that much money we just like to avoid spending money
well thank you so much for joining us today taking time out of your busy clinical schedule um
[Laughter] has many downsides but second year is
great
um thank you also to Dr iskin for taking time out of her busy clinical schedule because I know you're going to go right
back and see patients um that's true I think with that if folks have other questions and want to
stick around and ask them for a couple more minutes feel free but I think we're otherwise done for the day and you all
get sort of an hour of some extra Wellness time here this morning
Hillary do you have to go right back or can I ask you a question you can ask me a question until 10 30 and then I have
to go back okay around for a couple minutes well well the the quick question is
um whether you're having fun and enjoying this yeah it is fun okay yeah
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